Preterm Contractions Checklist

Preterm Contractions Checklist 
1. Is the gestational age less than 37 weeks? 
[select value="Unknown|No|Yes"] <-- Are dates certain? 
[select value="Unknown|No|Yes"] <-- Established by LMP or early ultrasound? 
[textarea]
2. Are the membranes ruptured? 
[select value="Unknown|No|Yes"] <-- History of leaking fluid? 
[select value="Unknown|No|Yes"] <-- Positive nitrazine test result? 
[select value="Unknown|No|Yes"] <-- Ferning of fluid on microscopy? 
[select value="Unknown|No|Yes"] <-- Positive amniotic protein test result? 
[select value="Unknown|No|Yes"] <-- Ultrasound assessment shows low amniotic fluid? 
[select value="Unknown|No|Yes"] <-- Ultrasound-guided transabdominal instillation of indigo carmine dye into the amniotic sac, if available, shows dye outside the amniotic sac? 
[textarea]
3. Is the patient in labor? 
[select value="Unknown|No|Yes"] <-- Regular contractions 
[select value="Unknown|No|Yes"] <-- Progressive dilation and cervical effacement? 
[textarea]
4. Is there an infection? 
[select value="Unknown|No|Yes"] <-- Group B streptococcus carrier status? 
[select value="Unknown|No|Yes"] <-- Urinary tract infection? 
[select value="Unknown|No|Yes"] <-- Bacterial vaginosis? 
[select value="Unknown|No|Yes"] <-- Trichomoniasis? 
[select value="Unknown|No|Yes"] <-- Gonorrhea? 
[select value="Unknown|No|Yes"] <-- Chlamydia? 
[textarea]
5. What is the likelihood that the patient will deliver prematurely? 
[select value="Unknown|No|Yes"] <-- Fetal fibronectin test negative? 
[select value="Unknown|No|Yes"] <-- Cervical length of at least 3 cm on ultrasonagraphy? 
[textarea]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).isNot('')"] 
Reference:
[link url="https://www.ncbi.nlm.nih.gov/pubmed/20148502" memo="#1"] Sayres WG Jr. Preterm labor. Am Fam Physician. 2010 Feb 15;81(4):477-84. [/conditional]